Human Behaviour Notes Slideshow PDF

ALL HUMAN BEHAVIOR SLIDES This Photo by Unknown Author is licensed under CC  PARA1043: HUMAN BEHAVIOURS AND CRISIS INTERVENTION N. SPARROW PARA1043 SEPT 2024 MENTAL HEALTH  What is ‘Mental Health’? A state of psychological, emotional a...

ALL HUMAN BEHAVIOR SLIDES This Photo by Unknown Author is licensed under CC  PARA1043: HUMAN BEHAVIOURS AND CRISIS INTERVENTION N. SPARROW PARA1043 SEPT 2024 MENTAL HEALTH  What is ‘Mental Health’? A state of psychological, emotional and social well-being What are the key indicators of someone who is ‘Mentally Healthy’? DISCUSSION Ability to think logically and rationally Ability to choose amongst thoughts and emotions, move flexibly between them Ability to match moods and emotional expressions to situation Ability to cope with change, stress, trauma Ability to accept limitations and boundaries Ability to be productive and achieve our potential Ability to make meaningful contributions to society  Disrupts the way a person thinks, feels or behaves Brain is just like any other organ - vulnerable to illness Stigma – often mental illness is looked upon and treated differently to physical illness MENTAL ILLNESS Causes are complex Partly biological (genes, brain structure/chemistry, illness/injury) Partly developmental (adverse childhood experiences or neurodevelopmental differences) Partly environmental (social issues, poverty, violence, food insecurity) MASLOW’ S HIERARCH Y OF NEEDS  Thinking about Maslow’s Hierarchy of needs, can you identify groups of people who are at higher risk of mental illness? DISCUSSION  1.Income and social status 2.Employment and working conditions 3.Education and literacy 4.Childhood experiences 5.Physical environments SOCIAL 6.Social supports and coping skills DETERMINAN 7.Healthy behaviours TS OF 8.Access to health services HEALTH 9.Gender 10.Culture & Race Equity vs Equality? https://www.canada.ca/en/public-health/services/health-promotion/ EQUITY VS EQUALITY CRISIS MANAGEMENT  What is a mental health ‘crisis’? Developmental Crisis: Crisis resulting from a normal/expected life change Puberty Leaving home Marriage Birth of children CRISIS Retirement Situational Crisis: Crisis resulting from an unexpected trauma, loss or change Death Divorce Critical illness/injury Assault/Violence Property destruction  What is our role in crisis management? CRISIS Developmental Crisis: MANAGEMEN Goals for assessment? T Management? Situational Crisis: Goals for assessment? Management?  Sympathy: You understand the feelings the other person is having, but do not necessarily share them Empathy: You are feeling the same feelings as the other person, you have experienced similar and can directly relate Pity: A superficial response to a person’s suffering KEY TERMINOLOG Compassion: Sympathetic concern for the feelings and misfortune of others Y Diplomacy: The art of dealing with people in a sensitive, yet effective manner Tact: Using skill and sensitivity when dealing with difficult situations Discretion: The quality of behaving or speaking in such a way as to avoid causing upset or offense, or revealing private information  EMOTIONS AND EMOTIONAL REACTIONS What types of emotional reactions might we see as paramedics? Typical? Atypical?  “Healthy” Religion Seeking social support Seeking professional support Exercise/meditation COPING MECHANISMS ‘Unhealthy” Substance Use Risky Behaviours Isolation Overworking Avoidance/Denial  How can we provide emotional support on a difficult call? PROVIDING Words EMOTIONAL Proximity SUPPORT Presence Touch Time  Avoid using negative words which perpetuate stereotypes, prejudice, or discrimination (Stigmatizing language): Crazy, Nuts, Mad Drug addict, drug user Try ‘has a substance use disorder’ or ‘Uses _____ regularly’ WORDS Try to mimic the the language the person uses: Schizophrenic/Has schizophrenia MATTER! Autistic/Has autism With respect to suicide and self-harm: ‘Commit’ implies it is a sin or crime ‘Successful/Unsuccessful’ imply there is an aspect of achievement Try ‘Died by suicide’ or ‘fatal vs non-fatal suicide attempt’ or ‘is having suicidal thoughts/ideations’  PARA1043: MOOD, PERSONALITY AND PSYCHOTIC DISORDERS N. SPARROW PARA1043 SEPT 2024  Presents with intense symptoms such as stress, Neurosis:anxiety or obsession, but individuals maintain a grip on reality Set of symptoms characterized by a loss of touch with reality. During a psychotic episode, thoughts and perceptions are disturbed, and the individual may have difficulty understanding what is real and PSYCHOLOGIC Psychosis: what is not AL Extreme and abnormally elevated mood, energy, MANIFESTATIO emotions or activity levels, which is a marked change from the usual baseline N DEFINITIONS Mania: Daily Routine? Coping Mechanisms/Abilities? Relationships? Perceived Reality?  Delusion:Fixed, false beliefs which continue to be held despite clear or reasonable evidence that they are not true. Cannot be corrected with logic and are not shared by others of same culture/educational level. Misinterpretations of actual external sensory stimuli PSYCHOLOGIC Illusion: AL Experience of hearing, seeing, smelling, tasting, MANIFESTATIO or feeling things that are objectively not there. Often vivid and clear to the individual, consistent N with normal perceptions. Auditory hallucinations, “hearing voices,” are the most common Hallucination: DEFINITIONS Daily Routine? Coping Mechanisms/Abilities? Relationships? Perceived Reality?  Paranoia:Irrational and persistent feeling that people are 'out to get you' or that you are the subject of persistent, intrusive, unwanted attention by others. Repeated thoughts, urges or mental images, which are intrusive and unwanted, usually PSYCHOLOGIC Obsession: resulting in marked fear or anxiety AL MANIFESTATIO Uncontrollable, persistent and excessive fear of a certain object, creature, situation or activity, N which are often irrational. DEFINITIONS Phobia: Daily Routine? Coping Mechanisms/Abilities? Relationships? Perceived Reality? MOOD DISORDERS  Minimum 2-week history of pervasive low mood which Major De impacts day-to-day life pressive Disorder Mood Consistent, uncontrollable, Disorde Generalize excessive worry and d Anxiety anxiety, for 6 months or rs Disorder more Extreme mood swings and Bipolar Di intense emotional states, sorder often at either end of the spectrum  Depressed or low mood, for most of the day, more days than not Loss of interest or pleasure in previously enjoyed activities Weight loss or weight gain DEPRESSIO Insomnia/Hypersomnia N Inability to concentrate When Feelings of worthlessness/guilt are paramedics most likely to see these Thoughts Are there patients? of death or suicidal any safety ideation concerns? What should our psychiatric assessment look like? What are our treatment goals?  Excessive worry and anxiety Restlessness/agitation Difficulty resting or sleeping Fatigue Impaired concentration ANXIETY Irritability Hypervigilance When are paramedics most likely to see these Generalized aches and pains patients? Are there any safety concerns? What should our psychiatric assessment look like? What are our treatment goals?  Previously called ‘Manic Depression’ Bipolar I: Often have extreme manic episodes, with few or no significant depressive episodes BIPOLAR DI SORDER Bipolar II: Often experience less severe ‘highs’ (hypomanic episodes), alongside When are paramedics most likely to see these major depressivepatients? episodes Are there any safety concerns? What should our psychiatric assessment look like? What are our treatment goals? PERSONALITY DISORDERS  Cluster A: Paranoid Personality Disorder Schizoid Personality Disorder Odd and Schizotypal Personality Eccentric Disorder Personali Cluster B: Antisocial Personality Disorder Dramatic Histrionic Personality Disorder ty and Narcissistic Personality Disorder Disorders Erratic Borderline Personality Disorder Cluster C; Avoidant Personality Disorder Fearful Obsessive-Compulsive and Personality Disorder Dependent Personality Anxious Disorder  Odd & Eccentric Paranoid Personality Disorder: Irrational suspicion and mistrust of others Interpretation of all/most actions as malevolent CLUSTER A Accusatory/blaming of others or organizations Schizoid Personality Disorder How do these affect their Prefer to be alone, voluntary isolation and reclusive behaviour daily lives? Apathy towards, and detachment from social relationships When are paramedics Minimal or restricted emotional expression most likely to see these patients? Are there any safety concerns? Schizotypal Personality Disorder What should our Odd, eccentric thoughts and behaviour psychiatric assessment Individual/peculiar appearance look like? ‘Magical thinking’ and distorted perceptions What are our treatment Difficulty interacting socially goals?  Dramatic & Erratic Antisocial Personality Disorder: Disregard for, and violation of needs/rights of others Lack empathy, often self-aggrandizing, impulsive and manipulative Often have socio and psychopathic tendencies, with hx of CLUSTER B criminal behaviour from young age Histrionic Personality Disorder Exaggerated emotional responses, attention-seeking behaviours Different presentations: flirtatious, seductive, flamboyant, ‘larger than life’ Is uncomfortable if not the centre of attention  Dramatic & Erratic Narcissistic Personality Disorder: CLUSTER B Egocentric, self-aggrandizing, feels superior to others Need for admiration and to be well-thought of Lacks empathy, will exploit others for own gain How do these affect their daily lives? When are paramedics most likely to see these patients? Borderline Personality Disorder Are there any safety Very unstable emotions - abrupt mood swings, with concerns? impulsive, self-destructive behaviours (including self-harm) What should our Rapid and dramatic shifts in likes/dislikes, body image psychiatric assessment perception, goals etc. No firm grasp on who they really are. look like? Volatile, intense and unstable relationships What are our treatment goals?  Fearful & Anxious Avoidant Personality Disorder: Desire companionship, but intense fear of rejection/negative feedback Social discomfort and ineptitude Involuntary isolation and reclusiveness CLUSTER C Obsessive-Compulsive Personality Disorder Rigid conformity to ‘rules’ Uncontrollable and recurring thoughts (obsessions) How do these affect their Engages in repetitive behaviours or rituals (compulsions) daily lives? When are paramedics most likely to see these Dependent Personality Disorder patients? Inability to care for oneself (not through physical Are there any safety disability) concerns? What should our Lack confidence, fear being alone, unable to psychiatric assessment make decisions look like? Feelings of helplessness and need for constant What are our treatment reassurance, excessive reliance on others goals? PSYCHOTIC DISORDERS  Characterized by incoherent or illogical thoughts, bizarre Psychot Schizophre nia behavior and speech, and delusions or hallucinations ic Disorde rs Delusiona Characterized by one or more firmly held false belief(s) that l Disorder persist for at least 1 month How do these affect their daily lives? When are paramedics most likely to Other PTSD see these patients? Post-Partum Psychosis Are there any safety concerns? Psychose Drug-Induced Psychosis What should our psychiatric s Stress-Induced Psychosis assessment look like? What are our treatment goals? CONVERSION DISORDERS  Psychiatric Disorder producing physical symptoms These symptoms are NOT the result of attention-seeking behaviour or falsification Cannot be controlled by patient Symptoms often appear inconsistent (changes with distraction or in different settings for e.g.) CONVERSIO Examples: N Psychogenic Non-Epileptic Seizures (most common) DISORDERS Used to be called ‘pseudo-seizures’ Paralysis or weakness No specific pattern In contrast to true paralysis/paraplegia, will retain deep tendon reflexes and Babinski reflex Abnormal movements Tic, tremor, myoclonus, gait abnormalities Sensory loss/alterations Blindness/deafness, loss of taste/smell, somatic sensation  How might this affect: Daily Routine? Coping Mechanisms/Abilities? Relationships? Perceived Reality? CONVERSIO N DISORDERS When are paramedics most likely to see these patients? Are there any safety concerns? What should our psychiatric assessment look like? What are our treatment goals?  PARA1043: SUBSTANCE MISUSE, VIOLENCE & AGGRESSION N. SPARROW PARA1043 SEPT 2024  ADDICTION & SUBSTANCE MISUSE  Young people aged 15 to 24 are more likely to experience substance use disorders than any other age group Men have higher rates of substance use disorders than women People with a mental illness are twice as likely to have a substance use disorder compared to the general population. ADDICTION People with substance use disorders are up to 3 times more STATISTICS likely to have a mental illness. (CAMH.CA) It is estimated that 67,000 deaths per year are attributable to substance use in Canada. Over 47,000 deaths attributable to tobacco, and Nearly 15,000 deaths attributable to alcohol Estimated 14,700 opioid-related deaths in Canada between January 2016 and September 2019  Any behaviour that is ‘out of control’ in some way Substance use becomes a problem when there are either: Harmful Consequences Injuries, anxiety, relationship problems, legal problems, risky behaviours ADDICTION Loss of Control Continued use despite wanting to stop or using more than intended Addiction is commonly described by 4 C’s: Craving Loss of Control (amount or frequency) Compulsion (to do or use) Continued use despite Consequences  Genetic Vulnerability Predisposition - addictive personality Drug-Brain Interactions Dopamine – immediate feel good WHY DO Pain relief PEOPLE Environment BECOME Exposure to substance abuse in the home ADDICTED? Peer pressure Coping Mechanisms Abuse or trauma Stress MH issues  Schedule I: Highest potential for harm and/or abuse Opioids, Cocaine; Amphetamines, PCP, MDMA Schedule II: Cannabis, Cannabinoid derivatives, Hashish CONTROLLED DRUGS AND S Schedule III: UBSTANCES A LSD, Psilocybin CT (1996) Schedule IV: Barbiturates, Benzodiazepines, Anabolic Lower potential for Steroids harm and/or abuse  Scheduled vs Unscheduled Drugs Scheduled drugs have restrictions on their sale and/or use Unscheduled drugs can be sold from any outlet, without doctor or pharmacist oversight Schedule I Prescription-only drugs HEALTH CANA Schedule II: No prescription required, can be sold by pharmacist. Must be kept in area DA: NATIONAL inaccessible to public DRUG SCHED ULES Schedule III: No prescription required, can be sold from self-selection section of an approved pharmacy Unscheduled: No prescription required, can be sold without professional supervision  Alcohol Caffeine COMMON Tobacco (Nicotine) DRUG Cannabis GROUPS Opioids (DSM-V) Stimulants Sedatives, Hypnotics and Anxiolytics Hallucinogens  Class/Type: Depressant Alternate names: Liquor, booze, ethanol, ETOH Common forms: ALCOHOL Wine, Beer, Spirits, etc FACTSHEET Mouthwash (Yellow Listerine) Method of use: Drinking Most common form of addiction  S/S Acute Alcohol Overdose: Mental confusion, stupor Reduced LOC Slow, irregular breathing ALCOHOL Bradycardia OVERDOSE Low temperature; pale, clammy skin; Dulled responses, loss of protective reflexes Vomiting Seizures  Chronic Alcohol Use: HTN Higher risk of strokes and heart attacks ALCOHOL USE: Liver disease/Liver failure CHRONIC Ascites Wernicke-Korsakoff Syndrome Thiamine (Vit B1) deficiency Acute encephalopathy Chronic memory issues and amnesia Alcohol-induced hypoglycemia Inhibits gluconeogenesis  Alcohol Withdrawal: Mild symptoms can begin within 6 hours of stopping drinking Signs and Symptoms ALCOHOL Mild/Moderate: Hypertension, tremors, anxiety, WITHDRAWAL GI upset, headache, palpitations, insomnia Delirium tremens (DTs): severe form of alcohol withdrawal Visual and auditory hallucinations, whole body tremor/spasms, significant GI upset, diaphoresis, tachycardia and hypertension Withdrawal seizures  A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 or more of the following, occurring at any time in the same 12-month period: Alcohol is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. Craving, or a strong desire or urge to use alcohol. ALCOHOL Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. USE Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. Important social, occupational, or recreational activities are given up or reduced because DISORDER of alcohol use. Recurrent alcohol use in situations in which it is physically hazardous. DSM-V Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of alcohol  Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for alcohol Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms  Antabuse: Causes flushing, nausea and palpitations Psychological deterrent AUD MANAGEMENT Naltrexone and Topiramate: Makes drinking alcohol less ‘rewarding’ Anti-craving medications  Class/Type: Stimulant Alternate names: None Common forms: CAFFEINE Coffee/Tea FACTSHEET Soda/Energy Drinks Chocolate/Cocoa Supplements and tablets Method of use: Eating/Drinking Supplement Powders/Tablets  Headache Fever Nausea/Vomiting Tachycardia and tachycardic dysrhythmias (VT/SVT) Hypertension Dizziness CAFFEINE Tinnitus INTOXICATION/ Dilated pupils OVERDOSE Anxiety/irritability Insomnia Seizures Toxic levels can cause fatal electrolyte imbalances and renal failure Arrhythmias are considered the most common cause of caffeine- related death  Withdrawal symptoms usually begin 12-24 hours after stopping or reducing caffeine intake Headache CAFFEINE Fatigue WITHDRAWAL Decreased energy Decreased LOC/drowsiness Depressed mood/irritability Difficulty concentrating Feeling ‘foggy’ – difficulty thinking clearly  Class/Type: Stimulant Alternate names: Cigs/smokes/darts, Chew, Snuff, Shisha Common forms: NICOTINE Cigars/Cigarettes Vapes/E-cigarettes FACTSHEET Hookah Smokeless tobacco (chewing/snuff) Method of use: Inhaling smoke/steam Chewing Wads in cheek/gum Snorting/Nasal  Early/Mild: Nausea/Vomiting Tachycardia and Hypertension Tachypnea Headache Salivation Dizziness or tremors NICOTINE Confusion and anxiety INTOXICATION/ OVERDOSE Late/More Severe: Diarrhea Shallow breathing/respiratory failure Bradycardia and Hypotension Extreme fatigue Seizures Weakness, slow reflexes, or unable to control muscles Pale, cool, clammy skin  Class/Type: Difficult to classify (Depressant/Stimulant/Hallucinogen effects) Alternate names: Marijuana, Weed, Pot, Hash, Wacky Backy, Grass, Mary Jane, Ganja etc, etc, etc… CANNABIS Common forms: FACTSHEET Flowers and leaves Oils, waxes and resins Edibles Tinctures/sprays/creams Method of use: Smoking/Inhaling Eating/drinking  Extreme anxiety/panic attacks. Psychotic reactions Paranoia Hallucinations Delusions Decreased judgment, perception, and coordination CANNABIS Tachycardia INTOXICATION/ Sudden hypertension OVERDOSE Headache Chest pain Tremors Seizures Pallor Reduced LOC  Cyclical nausea, excessive vomiting, and abdominal pain after using cannabis. Characterized by CANNABINOID Several years of cannabis use HYPEREMESIS A cyclical pattern of hyperemesis every few SYNDROME weeks to months Resolution of the symptoms after cessation of cannabis use, confirmed by a negative urine drug screen Symptoms are often relieved by hot baths or showers  Medically prescribed to control or ease symptoms of other diseases or disorders, including: Alzheimer's disease Amyotrophic lateral sclerosis (ALS) HIV/AIDS MEDICAL Crohn's disease MARIJUANA Epilepsy and seizures Glaucoma Multiple sclerosis and muscle spasms Severe and chronic pain Severe nausea or vomiting caused by cancer treatment  Class/Type: Depressant Common Opioids: Fentanyl Heroin OPIOID Morphine Codeine FACTSHEET Oxycodone (Oxycontin, Percocet) Hydrocodone (Vicodin) Hydromorphone (Dilaudid) Alternate names: Fetty, smack, junk, dope, oxy’s  Usually white – but can be a variety of colours Presentations ‘Rocks’ OPIOID Powders Fentanyl FACTSHEET Tablets Often are mixed with methamphetamine, cocaine, benzodiazepines amongst other things  Methods of Use: Injecting Smoking OPIOID FACTSHEET Oral (Pills)  Intoxication: Miosis (pinpoint pupils) Respiratory Depression (Bradypnea) Altered LOC, drowsiness, confusion OPIOID INTOXICATION/ Overdose: OVERDOSE Unconscious Miosis Apnea Bradycardia Cardiac arrest  Mild/Moderate: Aches/pains Restlessness/Anxiety Lacrimation/Runny nose Sweating Inability to sleep/Frequent yawning OPIOID WITHDRAWAL Severe: Abdominal Pain Nausea, vomiting, diarrhea Dilated pupils/Blurry vision Tachycardia Hypertension Diaphoresis  Assesses 11 symptoms associated with withdrawal S – Sweating T – Tremor O – pupil size (O looks like a pupil) Scoring P – Piloerection CLINICAL OPIO 5-12: Mild 13-24 Moderate ID WITHDRAW T – Tachycardia 25-36 Moderately AL SCALE R – Restlessness Severe >36 Severe (COWS) Y – Yawning Req. ≥8 for suboxone treatment by paramedic I – Irritability or anxiety N – Nose running or eyes tearing G – GI upset (vomiting / diarrhea) Joints – Joint pain or bone pain  Naloxone: Opioid antagonist used in acute overdose Blocks opioid receptors temporarily Methadone: Safer, longer acting opioid, used to reduce illicit opioid use Reduces cravings, without sedative/depressant effects (at correct dose) OPIOID ADDICTION Naltrexone: Used once a person has stopped using opioids regularly MANAGEMENT to remain opioid-free Suboxone: Mixture of buprenorphine (similar to methadone) and naloxone Reduces cravings, without sedative/depressant effects (at correct dose) Buprenorphine: partial opioid agonist – activates opioid receptors Naloxone is not well absorbed SL/PO – included to avoid misuse of suboxone  Crystal Meth Class/Type: Stimulants Common Stimulants: Amphetamines (Adderall) Methylphenidate (Ritalin, STIMULANT Concerta) FACTSHEET Methamphetamine (Meth, Crystal Meth, Ice) Cocaine/Crack (Coke, Blow, Nose candy, Nose beers) Cathinones (Bath Salts) Synthetic Cathinones Methods of Use: Injecting Snorting/Nasal Smoking Oral (pills) Crack Cocaine  Dilated pupils Hyperactivity Tachycardia Chest pain METH Twitching, facial tics, jerky movements INTOXICATION/ OVERDOSE Anxiety/Paranoia Aggression Skin sores Rotting teeth  Anxiety/Panic/Fear Restlessness/Agitation Talkative/High Energy Dilated pupils COCAINE Tachycardia and tachydysrhythmias INTOXICATION/ (VT/SVT) OVERDOSE Hypertension Heart attack Psychosis  Usually results from stimulant drug use Extreme agitation, aggression and violent behaviour Altered mental status Hyperthermia and diaphoresis Tachycardia and hypertension Increased pain tolerance EXCITED DELI ‘Superhuman’ strength RIUM Often require restraint and/or sedation 1 in 10 cases end in cardiac arrest Excessive dopamine – strain on heart Electrolyte imbalances & Rhabdomyolysis Asphyxiation during restraint  Common Drugs of Abuse: Benzodiazepines (diazepam, lorazepam, midazolam) Ketamine (Special K) GHB (Gamma HydroxyButyrate) SEDATIVES, PCP (Phencyclidine) HYPNOTICS & Nitrous Oxide ANXIOLYTICS FACTSHEET Methods of Use: Injecting Snorting/Nasal Inhaling Oral (pills)  Signs and Symptoms: Drowsiness/Dissociation/LOC SEDATIVES, Slurred speech HYPNOTICS & Confusion ANXIOLYTICS Shallow, slow or absent breathing OVERDOSE/ INTOXICATION *With Ketamine, hypersalivation  Common Drugs of Abuse: LSD Produces a kaleidoscope of visual patterns and changes perception Psilocybin (Magic Mushrooms) Alters senses – seeing music or hearing colours Ketamine Dissociation and ‘out of body’ experiences HALLUCINOGE Ecstasy (MDMA) NS Enhances mood, Increases feelings of love, empathy and intimacy Methods of Use: Injecting Snorting/Nasal Inhaling Oral (pills)  Unpleasant experiences, often known as ‘Bad Trip’ HALLUCINOGE NS Common symptoms: OVERDOSE/ Feeling that time is standing still INTOXICATION Extreme paranoia Fear and intense emotional distress Frightening hallucinations/delusions Agitation/violence Negative thought spirals Emotional mood swings VIOLENCE & AGGRESSION  Conflict Assertiveness Aggressiveness Violence KEY Assault TERMINOLOGY Battery Aggressive vs Assertive Behaviour? AGGRESSION VS ASSERTION VIOLENCE & AGGRESSION  Defusing/De-Escalation Techniques MANAGING Self-protection and self-defense AGGRESSION AND Restraint VIOLENCE Physical Chemical (ACP only) Electrical (Police only)  TREATING/ TRANSPORTIN G WITHOUT CONSENT  Restrain patients ONLY when: Directed by physician/police Unescorted pt becomes violent en route Required to provide emergency treatment and pt is non-compliant Key points: If physician directed, ensure appropriate paperwork and PHYSICAL escort is present If in handcuffs, police must travel in vehicle with you RESTRAINT Always secure restraints to body of stretcher Only 2 approved restraint positions: Supine, with one arm above head and one at waist level Side-lying (facing you!) with both hands secured to one side Raise head for airway protection and monitor closely Consider less invasive restraint for elderly (E.g: Blanket burrito)  If unable to safely manage patient with physical restraint, can request ACP assistance CHEMICAL Midazolam RESTRAINT Ketamine  Electronic Control Device (ECD/TASER) Each shot throws two probes May require removal to allow safe transport Try to avoid removing probes embedded in the following areas: Above clavicles ELECTRICAL In/close to nipples RESTRAINT In genital areas Probes are barbed Hold skin taught and pull upwards quickly Police may require probes to be left in place or retained for SIU investigation/evidence  PARA1043: VICTIMS OF ABUSE N. SPARROW PARA1043 OCT 2024  Child Abuse WHICH GROUPS ARE MOST Elder Abuse SUSCEPTIBLE? Intimate Partner Violence  Physical Abuse Any intentional act which causes trauma or bodily injury Sexual Abuse Any non-consensual or exploitive sexual behaviour/ activity imposed upon an individual without consent. Emotional/Psychological Abuse TYPES OF Regular and deliberate use of words and non-physical actions to ABUSE? hurt, manipulate, demean, confuse, frighten or otherwise control another individual Neglect Failure to provide for or meet a dependent’s basic physical, emotional, educational and/or medical needs. Financial Abuse Using an individual’s finances to exploit or control that individual PHYSICAL ABUSE  Sometimes referred to as Non-Accidental Injury Hitting (with hands or objects) Slapping or punching Kicking PHYSICAL Shaking ABUSE Throwing Burning or scalding Biting or scratching Breaking bones Drowning Poisoning or causing a child to become unwell Manufacturing illnesses  Accidental vs Non-Accidental? Consider age and ability ANY physical injury in a non-mobile child is PHYSICAL cause for concern ABUSE: Toddlers/Pre-Schoolers/Early School Age – CHILDREN covered in bruises and injuries! Consider story/mechanism and placement of injuries Accidental injuries become less frequent in older children Exception: Sport-related injuries Torn Frenulum  Fearfulness (unusual for age/stage of development) Particularly of parent/caregiver Odd behavior for age/stage of development Bedwetting, acting younger or older than expected PHYSICAL ABUSE: Hypervigilance NON-PHYSICAL Jumpy, anxious, always ‘on guard’ SIGNS & SYMPTOMS Overly compliant, unusually calm when examined Especially painful procedures Dissociated Thousand-yard stare  PHYSICAL ABUSE: NON-PHYSICAL SIGNS  Accidental vs Non-Accidental? Consider age and ability Disabled/bed-bound adults should sustain PHYSICAL minimal injuries ABUSE: Elderly people and those on blood thinners ADULTS/ELDER bruise easily Elderly skin is much thinner and S susceptible to tearing/breakdown Consider the accompanying story in comparison to the presenting injuries Petechial Haemorrhage  Female Genital Mutilation (FGM): Predominantly in African countries, as well as some Middle East ern countries Type I, also called clitoridectomy: Partial or total removal of the clitoral glans and/or the prepuce. PHYSICAL Type II, also called excision: Partial or total removal of ABUSE: the clitoral glans and the labia minora, with or without CULTURAL/ excision of the labia majora. The amount of tissue that is removed varies widely from community to community. RELIGIOUS Type III, also called infibulation: Narrowing of the vaginal orifice with a covering seal. The seal is formed by cutting and re-positioning the labia minora and/or the labia majora. This can take place with or without removal of the clitoral glans/prepuce. Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: Pricking, piercing, incising, scraping or cauterization. PHYSICAL ABUSE: CULTURAL/ RELIGIOUS  Spirit or Demonic Possession In some belief systems and/or cultures, children who do not conform to perceived societal ‘norms’ may be assumed to be being possessed by a spirit or demon This often results in attempts to restrain, imprison and/or exorcise the child PHYSICAL “A Virginia man was convicted in the death of a 2-year-old who died during exorcism. Eder Guzman-Rodriguez beat his daughter Jocelyn ABUSE: to death in an attempt to rid her of the demon he believed was inside her.” CULTURAL/ “A childminder heard Victoria (8yo) being called a “wicked girl” RELIGIOUS before she told pastors that she believed Victoria was possessed by an evil spirit. Days later, Victoria died after being starved for days while tied up in a black plastic bag with her hands and feet bound, lying in her own excrement without heating between being beaten and burned.” “Nusayba (4yo) was disembowelled by her mother after she accused her of being possessed, with her father finding her body. Reports said the child’s heart and other organs had been removed and placed in different rooms.” SEXUAL ABUSE  Any form of sexual penetration Inappropriate sexual touching of a child, whether clothed or unclothed Forcing or encouraging a child to touch an adult in a sexual manner SEXUAL Forcing a child to strip or masturbate ABUSE: Taking, downloading, viewing or CHILDREN distributing sexual images of children Not taking measures to protect a child from witnessing sexual activity or images Engaging in any kind of sexual activity in front of a child, including watching pornography  Genital or anal pain, irritation, and/or bleeding Injuries to external genitalia or inner thighs Difficulty walking or sitting Torn, stained, or bloody underclothing Sexually transmitted diseases SEXUAL Child exhibiting distress when a particular ABUSE: caregiver approaches CHILDREN Child re-enacts the abuse through engaging in “mimicking” behavior, re-enacts the abuse during INDICATIONS play or age-inappropriate play with toys, self or others Bizarre, sophisticated or unusual sexual knowledge Seductive behavior Regression, anger, frustration, depression, isolation  Any contact or non-contact sexual activity which occurs without consent or understanding, or with forced consent Rape/Date rape Attempted rape/sexual assault Groping/forced kissing SEXUAL Exposing genitals ABUSE: Any other form of sexualized activity ADULTS Sexual exploitation of a person with a physical or psychological disability Long Term Care Facilities Group Homes Home Care Services  Human trafficking involves the recruitment, transportation or harbouring of a person and includes controlling or influencing their movements with the goal of exploiting, or facilitating the exploitation of, a person Victims are often young girls who are held hostage and forced into the sex trade. Often have a traumatic past, wanting to escape their current situation The most common type of trafficker is the ‘Romeo’ or ‘boyfriend’ trafficker who will lure a victim in online or in person with fancy gifts, promises of love and a better life. HUMAN Then held hostage and forced to ‘repay’ this debt TRAFFICKING Victim is introduced to drugs and isolated from friends and family, taking away her cell phone and her identification. Often, she is moved from hotel room to hotel room in different cities and sold by the trafficker for sex several times a day. Common in large cities and border towns Human trafficking can also be associated with slave/forced labour Children or adults in vulnerable positions are forced to work for little/no wages, to repay a ‘debt’ – often associated with bringing them into the country  HUMAN TRAFFICKING: SIGNS Tattoos/Brands: Crown, rose, barcodes, dollar signs, names Often at neck, wrist, collarbone areas  HUMAN TRAFFICKING: SIGNS Tattoos/Brands: Crown, rose, barcodes, dollar signs, names Often at neck, wrist, collarbone areas  Tattoos/Brands Young women inappropriately dressed for weather or for their age Young women in unusual places or company at odd times of day Controlling individual Trafficker often called ‘Boyfriend’ HUMAN Can be female, often called ‘Bottom’ – trusted worker for trafficker, helps recruit and control TRAFFICKING: Not knowing where they are, not being aware of SIGNS surroundings Coaching on how to speak to professionals – given limits to what they can say May only give basic information, may sound scripted Significant lack of eye contact, especially females with males Injuries – often hidden. Person is a ‘product’ for sale Hostility when questioned outside of script/limitations PSYCHOLOGICAL ABUSE  Humiliating or constantly criticizing Threatening, shouting at, or calling them demeaning names Making them the subject of jokes, or using sarcasm to demean Blaming and scapegoating Making them perform degrading acts Not allowing them to have friends Persistently ignoring them PSYCHOLOGIC Never saying anything kind, expressing positive feelings or AL ABUSE congratulating them on successes Manipulation Gaslighting Pushing a child for perfection, or being ignorant of their limitations Failing to promote a child's social development Failure to respond to a child’s emotional needs (Childhood Emotional Neglect) NEGLECT  Unmet basic needs: Food/Water Clothing Warmth Shelter Hygiene NEGLECT Inadequate access to health care services Inadequate education Inadequate supervision Inadequate protection from hazards Can include self-neglect (adults) FINANCIAL ABUSE  Pressuring, forcing or tricking someone into: Theft of money/possessions Lending or giving away money, property or possessions Selling or moving from their home Changing their will / power of attorney Signing legal or financial documents that they don't understand FINANCIAL Working for little or no money, including caring for children or grandchildren ABUSE Making a purchase they don't want or need Using their bank cards/cheques or withdrawing funds without consent Providing food and shelter to others without being paid Standard of living not in-keeping with person’s financial status No/limited access to own financial accounts PARAMEDIC ROLES AND RESPONSIBILITIES  You cannot find what you are not looking for… Privileged position of seeing inside a home without warning/prep time Insight into how the person/family live Look in the fridge (elderly) Odd behaviour is more noticeable in the home ASSESSMENT Children oddly quiet/compliant Lack of evidence of children living there Listen to how family members speak to or about patient/each other Especially elderly, dementia patients Try not to be too overt when assessing for additional injuries If abuse is suspected, don’t voice this openly Be slow and gentle with assessments when possible Some may be triggering for abuse victims  Assume nothing! DO NOT interrogate patient or caregivers Actively listen Probe GENTLY around story and listen for inconsistencies Continue to maintain a professional, polite manner HISTORY with those suspected of abuse/maltreatment Make no accusations or judgmental remarks TAKING Consent to examine, treat and transport may be withdrawn if you show suspicion Give the patient privacy away from family/caregivers to discuss/disclose any concerns Do not appear shocked, disgusted or any other strong emotion Do not question or belittle their experiences  Be aware of your OWN beliefs, biases and pre-judgements Poor ≠ neglected; rich ≠ well cared-for Nice clean home ≠ good home life Not meeting YOUR standards ≠ abuse Never make assumptions THERAPEUTIC APPROACH Conduct a thorough assessment and history taking Safe, private space Start with least invasive questions/assessments – build rapport Active listening, sensitivity, dignity, respect Reassurance  Paramedics must function as patient advocates Using our position of power to speak up on behalf of those in weaker or more vulnerable positions Paramedics are “mandated reporters” ‘Duty to Report’ any and all suspected or known cases of child PATIENT maltreatment This overrides professional confidentialities and PHIPA laws ADVOCACY & You have protection from liability DUTY TO Except in cases of malicious reporting or without reasonable grounds for suspicion REPORT Children in Need of Protection (CHILDREN) Call Children’s Aid Society Directly Will ask for child’s name, age (DOB if possible) and address Give as much detail about your concerns as possible Even if someone else says they will report, we ALL have to make a report Pass on any concerns to hospital staff at triage (privacy!)  Paramedics must function as patient advocates We have the same responsibility to adult patients as children with regards to advocacy: Using our position of power to speak up on behalf of those in weaker or more vulnerable positions Paramedics are “mandated reporters” PATIENT ‘Duty to Report’ any and all suspected or known cases of abuse involving an incapable adult ADVOCACY & This overrides professional confidentialities and PHIPA laws DUTY TO There is no CAS equivalent for adults Police report (emergency/non-emergency) REPORT Pass concerns on to ED staff (ADULTS) What about adults who have the capacity to consent, vulnerable or otherwise? Any adult with capacity is entitled to make their own decisions We cannot make a report or referral on behalf of a capable adult without their consent Give them options and help them in whatever way they will allow  What services are available? Police Children’s Aid Societies EXTERNAL Victim Services ASSISTANCE Crisis Centres Temporary shelters National Human Trafficking Helpline  PARA1043: SELF-HARM & SUICIDE N. SPARROW PARA1043 OCT 2024  Injur y Attempted Self Harm Suicide LOW HIGH inten inten t to t to die die Unintentional Suicide Suicide Deat h  Non-Suicidal Self-Injury Deliberate, self-inflicted destruction of body tissue without suicidal intent Are often frequent Often seen in adolescents and younger adults Mostly low lethality injuries SELF- HARMING Examples: BEHAVIOUR Cutting Biting Burning Hitting Self-Harm does not include tattooing/piercing or eating disorders Self-Harm Cycle  Common triggers (often situational/developmental crises): Co-morbid psychological conditions Abuse/childhood trauma Grief/loss Struggling with sexuality/gender identity Involvement with law enforcement REASONS Bullying BEHIND SELF- Body image Increased pressure (school/work/exams) HARMING Family/relationship issues BEHAVIOUR Impulsive behvaiours Common reasoning: Method of expressing or coping with complex emotions/unbearable distress Feeling of control Self-punishment A cry for help  Don’t make assumptions Try not to react to or comment much on the injury or the behaviour Minimizing the injury can feel like you are minimizing their emotional pain Don’t reinforce the behaviour by giving positive feedback THERAPEUTIC Avoid judgmental comments/tone APPROACH Non-suicidal self-harm is very private behaviour Try to remain: Calm Curious Non-judgmental Try to reduce shame and show genuine concern for their emotional wellbeing, as well as their physical wellbeing  Not all self-harming behaviours are pre- cursors to suicide Self-harming behaviours CAN escalate ESCALATION into suicidal behaviours Usually very different in nature than regular self-harm behaviours Related to the INTENT to die – changeable When self-harming behaviours fail to provide the same relief/release  Injur y Attempted Self Harm Suicide LOW HIGH inten inten t to t to die die Unintentional Suicide Suicide Deat h  Suicide Continuum Suicidal Suicidal Passive Suicide Death by Ideation Intent Death Wish Attempt Suicide (No Plan) (Plan)  Passive Death Wish: ‘I just wish I were dead’ / ‘Everyone’s life would be easier if I were dead’ Suicidal Ideation: I want to die, but don’t have a specific plan in mind SUICIDE Suicidal Intent: I want to die and plan on doing CONTINUUM X, Y or Z Suicide Attempt: I want to die and have done X, Y or Z Death by Suicide  Firearms Knives (Stabbing/Cutting) Hanging SUICIDE Suffocation/Asphyxiation PLANS Poisoning/Overdose Jumping Vehicular ‘Suicide by Cops’  Suicide is the second leading cause of death amongst young adults (15-34 yrs) Males are 3x more likely to die by suicide than females Women are more likely to suffer non-fatal attempts Men often choose more lethal methods Elderly suicide attempts (particularly elderly men) are much more SUICIDE: likely to be fatal More carefully planned FACTS Less likely to be found/rescued Physically less able to withstand the trauma Most suicides occur in the home Most near-lethal suicide attempts are attempted within 24 hours of a crisis Around 50% occur within an hour of deciding to attempt suicide Around 25% occur within 5 minutes of deciding to attempt suicide  Suicide only affects those with a mental health condition Once an individual has suicidal thoughts/actions, they will always be suicidal SUICIDE: MYTHS Talking about suicide will encourage/lead to suicide Most suicides happen without warning…  Don’t avoid the topic – be direct Try to talk in private when possible Ask about led the events that led to this situation Ask about relevant medical hx and previous attempts Don’t try to fix their problems – actively listen THERAPEUTIC Establish a rapport APPROACH Don’t leave them alone or allow them to go places alone Lockable rooms Remove anything which could be used as a weapon Utensils, keys, medications, shoelaces, belts…  Commit suicide: Criminality Successful suicide: Celebratory Failed attempt: Disappointment Use: Attempted suicide or died/death by WORDS suicide MATTER… Use ‘suicidal’ to describe the thoughts or behaviours – not the person When discussing suicidal behaviours, name them explicitly, don’t skirt around the topic  PARA1043: DEATH & DYING N. SPARROW PARA1043 NOV 2024  Chronic Illness: Conditions which last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Terminal Illness: CHRONIC VS Disease which cannot be cured or adequately TERMINAL treated, which is expected to end in the death of ILLNESS the patient Examples: Cancer Dementia COPD Organ Failure  Palliative Care: Care provided to a patient living with an incurable illness aiming to provide comfort and improve quality of life. Not dependent on time left to live - many patients receive palliative care for months to years before death Patients may still be receiving active treatment for their condition and may still wish to be resuscitated in an PALLIATIVE emergency VS END OF LIFE CARE End of Life Care: Identified as the final phase of life when the patient has only hours, days, or weeks to live Non-essential medications stopped/reduced; Focus is on pain relief/comfort, no active treatment May occur in the home, in hospice or in long term care settings Patients should have paperwork in place to prevent resuscitation in an emergency  DO: Ask directly what you want/need to know Use appropriate terminology DISCUSSING Be specific about your questions CHRONIC/ TERMINAL DON’T: ILLNESSES Dance around the topic Whisper ‘unpleasant’ words Don’t assume level or progression of illness  Genetic changes cause rapid and excessive multiplication of cells in a specific area Tumour: Benign or Malignant Where is it? Treatment CANCER (Radiotherapy/Chemotherapy/Surgery) Current or past? Dates? Metastases? Liver, Lungs, Brain, Bone, Lymph nodes Prognosis? DNR/ EOL plans?  DO NOT RESUSCITATE (DNR)  DO NOT RESUSCITATE STANDARD  DISCUSSION: IS IT OUR PLACE TO START EOL DISCUSSIONS WITH PATIENTS IN THE COMMUNITY WHO HAVE NO EOL PLANS?  DISCUSSION: YOU’RE DEALING WITH AN ELDERLY PATIENT HAVING A HEART ATTACK, WHO SUDDENLY GRABS YOU AND SAYS ‘DON’T LET ME DIE, I DON’T WANT TO DIE!’ YOU HAVE THE PATIENT’S VALID DNR ORDER IN YOUR HAND. WHAT SHOULD WE DO?  DO NOT RESUSCITATE STANDARD EXPECTED DEATH IN THE HOME (EDITH) EXPECTED DEATH IN THE HOME (EDITH)  MAID became legal in Canada in 2016 Bill C-14 (2016): Very strict eligibility Amended in 2021 (C-7) to expand eligibility Patient Eligibility: Eligible for publicly funded health care services in Canada (or in the applicable waiting period) 18 years of age or older MEDICALLY Capable of making health care decisions ASSISTED Have a grievous and irremediable medical condition, which means: the patient has a serious and incurable illness, disease or disability DEATH the patient is in an advanced state of irreversible decline in capabilities the patient is enduring physical or psychological suffering, caused by the medical condition (MAID) or the state of decline, that is intolerable to the person and cannot be relieved under conditions that they consider acceptable Be making a voluntary request Provide informed consent to medical assistance in dying Bill C‑7 expanded eligibility to MAID to individuals whose death is not reasonably foreseeable and strengthened safeguards for applicants, but included a temporary exclusion for persons whose sole underlying condition is a mental disorder. Persons whose sole underlying condition is a mental disorder will (potentially) be eligible for MAID as of March 2027. This was due to come into effect March 2024.  Usually occurs with a mixture of injected medications: Anxiolytics (Midazolam) Anaesthetic agents (Propofol/Phenobarbital) MEDICALLY Neuromuscular blocking agents ASSISTED (Rocuronium) DEATH (MAID) Occasionally also used: Analgesics (Lidocaine) Cardiotoxic medications (Potassium chloride/ Bupivacaine)  DISCUSSION: WHAT DOES NATURAL DEATH LOOK LIKE?  Activity level decreases significantly May speak and move less, often sleeping more and more Becoming resistant to movement or activity of any kind Sometimes pain related Interest in surroundings fades APPROACHIN May not respond to questions or begin to show little interest in previously enjoyable activities. G NATURAL This phenomenon has been described as “detaching” as the DEATH dying person withdraws, bit by bit, from life. Desire for food and drink ceases May have little, if any, appetite or thirst - lack of interest in food and fluids is normal and expected May have problems swallowing, resulting in coughing and choking with any attempt to ingest medications, food, or fluids. Abdominal discomfort as the gastrointestinal system slows down along with the rest of the body’s systems.  Bowel and bladder changes Constipation may become more evident, requiring increased use of stool softeners or laxatives to maintain comfort Loss of bladder control and functioning can also occur. Body temperature can decrease by a degree or more Skin may start to feel cold to the touch APPROACHIN G NATURAL Vital Signs Change Near the end of life, vital signs like blood pressure, heart DEATH rate and respirations can fluctuate and become irregular. Pain and Skin Breakdown May be able to verbally indicate that they are in pain If non-verbal, pain or distress may be evident from signs such as moaning/groaning, resisting movement or other outward demonstrations of discomfort. Muscles begin to waste (longer term) and wounds can develop suddenly (final stages)  Consciousness fades Before death, conscious level will reduce, eventually becoming completely unresponsive. Sensory changes It is not unusual for dying people to experience sensory changes (illusions, hallucinations, delusions) APPROACHIN These changes can wax and wane, often become more G NATURAL pronounced at night. DEATH Near death awareness They may report awareness of their imminent death Soon be able to see their God/religious figure Going to see loved friends and relatives who have died Preparing to take a trip, traveling, or activities related to travel, such as getting on a plane or packing a bag. Many find this awareness comforting, particularly the prospect of reunification.  Breathing Changes Terminal secretions (death rattle) Can be retained in the mouth if the patient is unable to swallow causing gurgling Does not indicate pain or suffering Cheyne Stokes Breathing Irregular breathing pattern with rapid breathing, NATURAL DEA followed by pauses TH Pauses will gradually lengthen Can spend minutes or hours in this phase Agonal gasps Very similar to Cheyne Stokes breathing, but without the associated pattern  DISCUSSION: WHAT CAN WE DO TO MAKE THE DYING PROCESS EASIER/MORE PEACEFUL? (PATIENT AND FAMILY) YOUR 98YO LTC PATIENT IS IN THE FINAL STAGES OF DEATH, WITH CHEYNE STOKES BREATHING PATTERN AND A WEAK CAROTID PULSE. SHE HAS A VALID DNR IN PLACE. STAFF CALLED FAMILY TO ADVISE THEM OF THEIR MOTHER’S DETERIORATING CONDITION. THE DAUGHTER ARRIVED ON SCENE AND HAS CALLED 911, DEMANDING THAT PARAMEDICS RESUSCITATE AND TRANSPORT HER MOTHER TO HOSPITAL. WHAT CAN/SHOULD WE DO? DECEASED PATIENT STANDARD  DISCUSSION: EXPECTED VS UNEXPECTED DEATH? DECEASED PATIENT STANDARD DECEASED PATIENT STANDARD DECEASED PATIENT STANDARD  What happens after an expected death? Patient requires death certificate Often processes already in place for this Family physician, LTC physician, Palliative Care Team As long as pathway exists and responsible PARAMEDIC person on scene, paramedics can leave RESPONSIBILITI ES If a patient has a DNR and dies ‘unexpectedly’ Police attend to facilitate next steps Paramedics should remain at scene to hand over custody of the decedent to officers  POLICE NOTIFICATION STANDARD  DEALING WITH FAMILY… DURING THE DYING PROCESS? AFTER THE DEATH? WHAT CAN/SHOULD WE DO?  Sudden (Medical) Cardiac Arrest Often occurs quickly – drop to floor Usually cardiac related - may still have agonal gasping May mentate throughout CPR – but this is not common Trauma Cardiac Arrest Usually result of blood loss, whether this is sharp or blunt SUDDEN Cardiac arrest following blunt force trauma is usually not DEATHS survivable and is eligible for a trauma TOR Sharp force trauma must always be transported When patients die whilst in your care, they will sometimes tell you that they know/feel that they are going to die Hypoxia can cause combativeness and air hunger  YOUR 17-YEAR-OLD TRAUMA PATIENT, WHO YOU KNOW IS BLEEDING PROFUSELY INTERNALLY GRABS YOU AND SAYS ‘I’M GONNA DIE, AREN’T I?’  MEDICAL TERMINATION OF RESUSCITATI ON  TRAUMA TERMINATION OF RESUSCITATI ON  To receive a TOR, we MUST patch to Base Hospital Physician If you are team lead: Communicate with the team about where we are in the resuscitation effort PARAMEDIC Communicate what the next steps are RESPONSIBILITI ES Communicating with the family Before or after the termination of resuscitation order is given is up to you Provide a death notification Explain the next steps Ask the family if they would like to see the decedent Always explain the situation and what they look like Provide comfort and support  Once you receive a TOR, you will need to write down the name of the doctor and the time of death Police will want this from you Police will also want your name and date of birth Advise your team to cease resuscitation Disconnect the monitor as soon as CPR is stopped DO NOT check for pulses CARE OF THE BODY Leave all IVs and airway management tools in place. You can disconnect bags of fluid and BVM etc Cover the body in one of the ambulance sheets/ blankets Don’t use family items Tidy up your mess… OBVIOUS DEATH DEPENDENT/ POSTMORTE M LIVIDITY HYPOSTASIS POSTMORTE M STAINING  Assess patient for signs of obvious death Note these for paperwork Note time pt confirmed dead There is no need to perform ECG monitoring to confirm a rhythm on obviously dead patients Assess patient and surroundings for any obvious signs of foul play PARAMEDIC Be aware of scene preservation just in case RESPONSIBILITI ES Attempt to determine patient’s identity (if unknown) Again, be aware of scene preservation Notify the family, even if it appears obvious Follow Deceased Patient Standard: Follow protocol as to whether death was expected or unexpected If suspicious death, notify police and attempt to preserve scene as best as possible for police  SUICIDES AND HOMICIDES  Try to find out the name of the patient and their relationship if possible, before giving a death notification Do not prolong the situation unnecessarily Be very clear and direct: Use the words DEATH DEAD or HAS DIED. NOTIFICATIO Ideally, you should say these more than once… N Don’t say: “Passed away” “Gone to a better place” “Is no longer with us” Anything based in religion (unless they start and you feel compelled to continue) Anything that is not true…  IS ANYTHING DIFFERENT ABOUT INCIDENTS INVOLVING DEATH OF A CHILD?  Shock and Denial Anger SURVIVORS: GRIEVING Bargaining PROCESS Depression/Pain/Guilt Acceptance  PARA1043: AGING, AGE-RELATED AND DEGENERATIVE DISORDERS N. SPARROW PARA1043 NOV 2024 AGING AND AGE-RELATED DISORDERS  Average life expectancy in Canada currently: 82 years Average life expectancy in 2000: 77 THE AGING years POPULATION Average life expectancy in 1980: 74 years WHY ARE WE LIVING LONGER? WHAT ISSUES MIGHT THAT CAUSE?  Hearing loss: Changes damage to inner ear structure Changes in the middle ear and nerve pathways from the ear to the brain AGING: Long-term exposure to noise HEARING AND Macular degeneration: EYESIGHT Central portion of your retina (macula) becomes worn Cataracts: Clouding of lens in the eye WHAT ISSUES MIGHT THESE CAUSE?  Osteoporosis: Bone disease Decreased mineral density Changes to bone structure and strength BONES AND Oestrogen – bone protective JOINTS Menopause increases osteoporosis risk/progression  Hyperkyphosis: ‘Dowager’s Hump’ Can be caused by prolonged ‘forward leaning’ posture Using a cane, walker etc BONES AND Can be sign of advanced JOINTS osteoporosis Vertebral collapse  Osteoarthritis: Degenerative breakdown of joints Common in knees, hips, spine and hands BONES AND JOINTS  Rheumatoid Arthritis Autoimmune, inflammatory disease Common in hands, wrists and knees BONES AND JOINTS WHAT ISSUES MIGHT THESE CAUSE?  Skin: Skin becomes thin and translucent Less elasticity More fragile CHANGES TO Bruises and tears easily BODY Loss of subcutaneous tissues TISSUES No padding No anchoring for veins Longer wound healing  Diabetes (Type II) Aging with obesity can lead to insulin resistance Aging in the absence of obesity can lead CHANGES TO to impaired β-cell function BODY TISSUES Issues? May be undiagnosed (insidious onset) High BGL irritates lining of blood vessels Damages peripheral nerves (neuropathies)  Atherosclerosis Irritation/damage to vessel walls Fatty deposits inside vessels CHANGES TO Calcification (hardening) of vessels BODY Narrowing of vessels TISSUES Risks?  Brain: Shrinks in size 5% per decade after age 40! Frontal lobe particularly Loss of cells (gray matter) CHANGES TO Demyelination BODY Loss of cell volume TISSUES Cognitive decline and diminished brain function Memory issues Struggle to learn new things WHAT ISSUES MIGHT THESE CAUSE?  Traumatic Brain Injury (TBI) Why? Cerebrovascular Accident (CVA) BRAIN INJURIES  Benign Prostatic Hyperplasia (BPH) Enlarged Prostate CHANGES TO BODY TISSUES DEMENTIA  Dementia Alzheimer’s Disease Amyloid plaques in the brain Vascular Dementia Caused by impaired blood flow to parts of the brain Lewy Body Disease DEMENTIA Protein deposits (Lewy Bodies) in the brain Frontotemporal Dementia Damage specifically to above mentioned areas – much more likely to have significant behaviour and personality changes Mixed Dementia As it suggests! Korsakoff’s Syndrome Alcohol-related dementia (Vit B1 deficiency)  DEMENTIA PROGRESSIO N  A state of increased agitation, confusion, disorientation and anxiety in individuals with dementia, typically occurring in the late afternoon/evening SUNDOWNIN G DELIRIUM  Parkinson’s Disease Loss of neurotransmitters (chemical messengers) Dopamine As disease progresses more cells which are capable of producing dopamine are PARKINSON’S lost DISEASE In earlier stages, most retain good brain function, but many develop dementia in later stages. PARKINSON’S DISEASE DEGENERATIVE DISORDERS NEUROMUSCULAR DEGENERATIVE DISORDERS Amyotrophic Motor Lateral Myaesthenia Huntingdon’s Neurone Sclerosis Gravis Chorea Disease (ALS) Multiple Guillain- Muscular Sclerosis Barré Dystrophy (MS) Syndrome  Rare neurological disorder – brainstem damage (pons) Retain full consciousness and normal cognitive abilities Paralysis of all voluntary muscles EXCEPT vertical movements of the eyes (up and down) and blinking Unable to show facial expression, speak, swallow or move Many are able to communicate using eye movements LOCKED-IN SYNDROME Causes: Stroke TBI (Pons) Tumours Demyelination ALS or Guillain-Barré Syndrome In some situations, recovery of some motor function can occur, but full recovery is unlikely LOCKED-IN SYNDROME  PARA1043: DEVELOPMENTAL DISORDERS & EATING DISORDERS N. SPARROW PARA1043 NOV 2024  DEVELOPMENTAL DISORDERS  ADHD Autism Spectrum Disorder Down Syndrome DEVELOPMENT Foetal Alcohol Spectrum AL DISORDERS Disorders/Syndrome Cerebral Palsy Cystic Fibrosis  ADHD = Dopamine deficient Overactive dopamine transporters Too many dopamine transporters Too little endogenous dopamine Or a mixture of these mechanisms! ATTENTION DEFICIT- HYPERACTIVITY Dopamine functions: DISORDER Endogenous ‘reward’ Also affects memory, movement, motivation, mood, attention etc Result = dopamine-seeking behaviours… It is these behaviours which characterise ADHD  Management: Stimulants Amphetamine and dextroamphetamine (Adderall) ATTENTION Methylphenidate (Concerta) DEFICIT- Lisdexamfetamine (Vyvanse) HYPERACTIVITY DISORDER Non-Stimulant options Clonidine (Kapvay) Atomoxetine (Strattera)  Developmental disability – differences in brain Anatomical and physiological AUTISM SPECTRUM DISORDER Diagnostic Criteria: (ASD) Social interaction / communication difficulties Restricted / repetitive behaviours Limited / specific interests Sensory differences HOW MIGHT YOU ADAPT YOUR PRACTICE?   Chromosomal defect which occurs during foetal DOWN development SYNDROME  Extra (third) copy of chromosome 21 (AKA TRISOMY 21)  Mild-severe intellectual impairment  Typical features:  Round head, flat occiput, enlarged tongue  Wide-set, upturned eyes  Heart defects, thyroid issues  Hearing and vision problems  Higher risk for certain medical conditions (cardiac, sensory, endocrine (diabetes), orthopaedic, dental, GI, neurological (epilepsy) and haematological  Airway management can be difficult in these patients due to facial and airway anatomy  FOETAL  Caused by alcohol use during pregnancy ALCOHOL SPECTRUM  Commonly referred to as Foetal Alcohol Syndrome DISORDER (FAS) (FASD) Symptoms:  Low body weight  Hyperactivity  Learning disabilities, poor memory and attention, poor reasoning/judgement  Hearing/vision impairment  Small head size, short nose, flat face with smooth philtrum   Non-progressive, bilateral neuromuscular disorder in which voluntary muscles are poorly CEREBRAL PALSY controlled  Caused by developmental brain insults in utero at birth or postpartum infections (encephalitis or meningitis)  Characterized by:  Spasticity in limbs  Altered muscle tone  Lack of balance/muscle coordination  Underdeveloped limbs  MAY have a degree of intellectual disability Symptoms range from mild to severe   Chronic dysfunction of the endocrine system (genetic)  CFTR gene – changes water transport  Targets multiple body systems (primarily respiratory and digestive) CYSTIC FIBROSIS  Creates very thick, sticky mucous inside organs – namely lungs and pancreas  Also affects stomach function  Respiratory symptomology:  Thick mucous build-up in lungs – difficult to clear  Tachypnea, productive cough, SOB, barrel chest, cyanosis, clubbed fingers  Often require respiratory physiotherapy  Manually dislodging mucous  Oscillating Positive Expiratory Pressure (PEP)  Vibrating vest   Digestive symptoms  Gastroparesis (delayed emptying)  Pancreatic blockage – limited digestion  Nutrient deficiencies and growth suppression CYSTIC FIBROSIS  Reduces life expectancy – many only live into teenage years  With aggressive and proactive management, life expectancy can be improved into 30s EATING DISORDERS  Bulimia nervosa Anorexia nervosa EATING DISORDERS Binge Eating Disorder Avoidant-Restrictive Food Intake Disorder (ARFID) Pica  Characterized by overeating, then significant calorie restriction Purging Type Bingeing: Eating much larger amounts of food than usual in shorter time frames Purging BULIMIA Vomiting NERVOSA Laxatives Non-Purging Type Bingeing: Eating much larger amounts of food than usual in shorter time frames Compensation Excessive exercise Fasting  Occurs in cycles - varying frequency Can repeat these cycles multiple times per day BULIMIA Mostly affects females NERVOSA Often starts in teenage years Often maintain normal or above average body weight Not recognized Often not treated until 30-50yrs old Habits are deeply ingrained Outward signs: Sore/inflamed throat Marks on knuckles (Russell’s Sign) Dental erosion  Again, more common in younger females Distorted body image ANOREXIA Intense fear of weight gain NERVOSA Severe calorie restriction Minimal eating Purging behaviours Excessive exercise  External signs: Extremely low body weight Visible skeletal structure Lanugo (Soft hair all over body) Marks to knuckles and dental erosion ANOREXIA Dry, brittle hair Dry, sallow skin NERVOSA Other signs Absent menstruation Osteoporosis Low oestrogen and high cortisol Break bones easily  Often have abdominal pain & constipation Causes irregular/absent menstruation Can be difficult to rule out pregnancy ANOREXIA Can cause significant electrolyte AND BULIMIA imbalances Particularly prominent with purging behaviours Low Potassium (hypokalaemia) Low Sodium (hyponatraemia) Can cause kidney damage (CKD) Can cause fatal arrythmias  Hypokalaemia Loss of potassium via purging Hypokalaemic nephropathy Destruction of renal tubules Kidney failure ELECTROLYTE Arrhythmias IMBALANCES Heart relies on sodium/potassium pump Other symptoms: Muscle weakness and cramping Including respiratory muscles (SOB) Severely slowed digestion Constipation & abdominal distension.  Hyponatremia Altered sodium : water ratio Restricted food intake with sustained water intake Can be worsened by SSRI medications (Selective Serotonin Reuptake Inhibitors) Can cause SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone) Causes kidneys to retain more water than usual ELECTROLYTE Chronic hyponatremia: IMBALANCES Headache & dizziness Lethargy Nausea & vomiting Muscle cramps Acute hyponatremia: Brain swelling ** Confusion Seizure Coma  Metabolic alkalosis (common with vomiting) Chronic loss of hydrogen and chloride ions Stomach acid ELECTROLYTE IMBALANCES Symptoms of severe metabolic alkalosis Muscle spasms, agitation Seizures, coma Monitor EtCO2 Hypercapnea is common (HIGH)  Metabolic acidosis (common with laxative use) Ketoacidosis Acidic ketones produced from fat breakdown Chronic loss of bicarbonate ions (alkaline/basic) Through stool (and urine) ELECTROLYTE Symptoms of severe metabolic acidosis IMBALANCES Increased HR Breathing changes (rapid/deep initially, slow/deep later) Confusion, nausea, vomiting Weakness, lethargy Monitor EtCO2 Hypocapnea is common (LOW)  Often eat a large amount of food in a short amount of time Eating when not hungry Continuing to eat until uncomfortably full Overeating as emotional/stress response Feelings of guilt/shame around eating BINGE Eating secretively EATING DISORDER No purging behaviours or compensation for calorie intake Usually affects women Usually present as overweight/obese  ARFID: Usually seen in children, can remain into adulthood if untreated or treatment is unsuccessful Extreme pickiness with food AVOIDANT- Avoidance of food based on colour/texture/sensation RESTRICTIVE Fear response when presented with certain FOOD INTAKE foods DISORDER Vomiting/gagging when exposed to certain foods Dependence on nutritional supplementation Sometimes external feeding tubes required Commonly co-occurs with autism  Persistently ingesting substances with no nutritional value  Dirt/soil Charcoal  Sand Hair PICA  Stones Pieces of metal